Tele-psychiatry shakes up Danish welfare system

Southern Denmark has begun a trial that, if successful, would mean patients suffering light to moderate depressions could be cured entirely online, without any face-to-face contact.

By Lucy Hinton and Emma Rose Haas, 12 December 2014

Lone tried traditional methods to treat her depression, but to no avail

Lone sat slowly stirring cream through her dark hot chocolate. She said she felt exhausted and drained. She could not focus or work. It felt like depression, the symptoms seemed to indicate depression, but still, she was anxious about going to a doctor. What a waste of their time, listening to her invisible problems, when there were other patients waiting with burns, coughs and broken bones. They might refer her to a psychologist, but then she would have to pay fees and join a waiting list. It might be weeks until she finally got to see someone. She could go straight to a private psychologist, but there was no way she could afford the on going treatment, and the waiting list could be even longer. The only option, she said, was to hope it passed.

It was at this stage of resignation that Lone stumbled upon Internetpsykiatrien, a trial for the treatment of depression online that begun in Region Southern Denmark June this year. A new form of telemedicine, where Lone could be treated from the comfort of her own house, in her own time, and, best of all, it would cost her nothing.

This project is part of regional, national and pan European projects. Southern Denmark is the first region to establish a Centre for Tele-psychiatry, the home of Internetpsykiatrien. Lone could participate in the trial for free because it is funded by the Danish government’s National Action Plan for the Dissemination of Telemedicine, and the European MasterMind project, which aims to make quality Internet based treatment for depression more widely available across Europe by February 2017.

An increase in knowledge about mental illness, and in particular depression, has put pressure on our health care system, says the Danish Agency for Digitisation, who are responsible for the implementation of the government’s digital ambitions in the public sector. There is now a widespread lack of psychologists and specialist psychiatrists. Geography is also a barrier to treatment, as specialized departments of hospitals are often placed far from local clinics.

The agency estimates that at any given time 10 – 20 percent of the Danish population will suffer a mental illness. That’s nearly double the population of Copenhagen, or 1,122,800 people, at worst. Of this, about 75,000 people suffer from light depression, says Karen Margrete, Board Member of the Danish Depression Union.

Cut the problem at its roots

“We literally have an enormous health problem in Denmark. Two thirds of depressed patients never even seek treatment,” says Kim Mathiasen, Project Manager of Internetpsykiatrien, “this is very damaging for employment and for our standard of living.”

People suffering light to moderate depressions, like Lone, are often uncertain about their illness, and reluctant to talk about it openly. If untreated, these symptoms can develop into more severe cases of depression, that have long-term negative implications for both the individual and society, such as long term absences from work, according a study by the National Research Centre for the Working Environment in Copenhagen.

Internetpsykiatrien uses computerized Cognitive Behavioural Therapy, a technique that encourages patients to develop alternative ways of thinking and behaving to reduces psychological distress. During the 10 week program all contact between patient and psychologist is online, through emails and exercises that are constantly monitored. It is, therefore, considered a ‘supported self-help’ style of treatment.

WATCH: See a psychologist working on the project

Community response to telemedicine in Southern Denmark

“Almost everyone was against it initially,” says Carl Holst, President of the Region Southern Denmark Council, “doctor’s were highly sceptical about reducing the amount of face-to-face time, families didn’t like the idea that their loved ones were being treated through a computer, but soon people saw that many more could be reached, at less of a cost and in the comfort of their homes.”

The Council of Southern Denmark embraced the National Action Plan immediately when it was established in August 2012. Now all employees at Psychiatric Hospitals within the region have access to video conferencing equipment, used to communicate internally and externally. This year Holst signed a deal with Internet provider Cisco, so that a safe and secure network could be established for the project. This reduces the risk of information theft or hackers.

If the evaluation report on the project released in March 2015 shows positive results, then this kind of treatment will be implemented all over Denmark. This puts pressure on other regions to create the infrastructure required to support the software.

“Other regions do not have this kind of infrastructure in place, and will struggle to implement this project if it is a success,” Holst says.

Annette Bang, Psychiatry Planning Chief for Region Central Jutland, says that her region is equipped to hold videoconferences internally at hospitals, but not with external patients. A secure and safe network is not yet in place. However, this region is investigating other ways to integrate telemedicine into their healthcare system, by creating an app helping to treat those suffering anxiety and phobias.

Denmark leads the way in Europe

These efforts from the Danish regions have not gone unnoticed. This November, Denmark was recognized for having the best digital opportunities for citizens and health professionals in Europe, by Healthcare Information and Management Systems Society, a non-profit organization, focusing on better healthcare through IT globally.

Below you can see the HIMMS-score for Denmark compared to Europe and countries/regions in the rest of the world (2014):
Screen Shot 2014-12-11 at 1.46.00 PM

Problems with the project

Internetpsykiatrien is limited in its ability to be tailored, or personalized. Its rigid structure means that patients suffering multiple mental illnesses cannot be treated. If, for example, the patient suffers from addictions or an eating disorder in addition to their depression, they must address these other issues before beginning the program.

“More flexibility will have to be built into this project if it were to become publicly available,” says Mathiasen.

Kit Lisbeth Jensen, a private Internet psychologist in Skagen, has been treating patients online since 2011. She says there are also major ethical issues that the Psychology Union must address if this kind of treatment were to be made more readily available.

READ MORE: Different telemedicine solutions: the pros and cons

“Although reducing geographical boundaries between patient and psychologist is great, it is also dangerous. If you notice a patient take a turn for the worse, you are physically too far to help them,” she says.

Price to pay

The treatment will be available free of charge until September 2015, when the project finishes. After that, it will be up to government policy makers to determine its continuation and cost.

As it is, the only costs of the project are the initial software installation and the webcam. This is a relatively inexpensive long-term investment, when you compare it to on going face-to-face psychology treatment that can cost 1000 DKK per hour, says Mathiasen. Patients have access to the program for 6 months after they finish their treatment, meaning that if Lone noticed herself having negative thoughts again, she had something to fall back on.

“Just the comfort of knowing the psychologist was there, keeping track of my progress, was enough. Also knowing that if there was a period of time where if I didn’t log in, she’d contact me. So there was still a certain pressure on me to finish the exercises,” she said.

For this reason the lack of human contact throughout the program did not concern Lone. In fact, it was a benefit. She did not have to waste time searching for a psychologist she felt she had “chemistry” with. She says online treatment put the power in her hands, unlike any treatment she had experienced before.